Provider Demographics
NPI:1336327915
Name:TYSON, KRISTIE M (PLPC)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:M
Last Name:TYSON
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11373 AMBOY LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6102
Mailing Address - Country:US
Mailing Address - Phone:314-355-6937
Mailing Address - Fax:
Practice Address - Street 1:11373 AMBOY LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6102
Practice Address - Country:US
Practice Address - Phone:314-355-6937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007034772101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional